188.3 🩺 內科專科考前版

188.3.0.1 1⃣ Culture-Negative Endocarditis Workup

  • Bartonella (cats, 街友) — serology + PCR
  • Coxiella (livestock exposure)
  • Brucella (livestock, unpasteurized dairy)
  • HACEK (oral flora, usually grows by 5-7 d)
  • Tropheryma whipplei (Whipple’s disease)
  • Fungal (Candida if IDU, immuno)
  • All require special serology + PCR; consider PET-CT for vegetation imaging

188.3.0.2 2⃣ Netherlands 2007-2010 Outbreak

  • Goat farm aerosol — 4000+ human cases
  • Goat dairy worker but also nearby residents (5 km)
  • Mass goat culling, vaccination
  • Lessons: occupational + community surveillance; rapid outbreak detection

188.3.0.3 3⃣ Q Fever Endocarditis Surgical

  • Valve replacement considered if:
    • Heart failure / hemodynamic instability
    • Failure to control with abx
    • Large vegetation, abscess
  • Continue doxy + HCQ ≥ 12 months post-surgery
  • Repeat valve eval — re-infection possible

188.3.0.4 4⃣ Hydroxychloroquine Dosing + Monitoring

  • 200 mg PO tid (or 400 mg bid weight-adjusted)
  • Levels for therapeutic 0.8-1.2 µg/mL
  • Retinal screening baseline + annual (high-dose long-term)
  • G6PD screen (hemolysis risk)
  • Photosensitivity counseling
  • Drug interactions (digoxin, amiodarone)

188.3.0.5 5⃣ Pregnancy Management

  • Acute Q in pregnancy → high placental fetal infection rate
  • TMP-SMX × until delivery + neonatal monitoring
  • Post-delivery: doxy + HCQ × 12 mo to prevent chronic
  • Follow-up pregnancies: counsel re-infection risk

188.3.0.6 6⃣ Q-Fever Fatigue Syndrome (QFS)

  • 20% of acute Q fever → persistent sx > 6 mo
  • Not active infection — prolonged antibiotic NOT helpful
  • Supportive: graded exercise, CBT, pain management, sleep hygiene
  • Counseling re chronicity, prognosis

188.3.0.7 7⃣ 健保 / Taiwan

  • Q fever 通報
  • Taiwan agricultural cases sporadic
  • 健保 doxy + HCQ covered
  • Bioterror potential — public health alert if cluster

188.3.0.8 8⃣ Bioterrorism Consideration

  • Coxiella burnetii Cat B agent
  • Aerosolized → large outbreak from small source
  • Cluster of acute Q with no clear livestock exposure → consider intentional release
  • Public health + FBI consult